::Screening Form

Welcome to the Online Screening Form. The data will only be sent to the Safety Officer of your parish, school or other location. All information entered on this form is kept private and secure.

This form is to be completed for all applicants for any position (volunteer or compensated). This is not an employment application. Persons seeking employment will be required to provide additional information. This process is used to help the church provide a safe and secure environment for children, youth and adults who participate in our program and use our facilities.

Volunteer means any unpaid person engaged in or involved in a Diocesan activity, and who is entrusted with the care and supervision of children and/or persons engaged or involved in ministry who have regular individual contact with the elderly or disabled. When you submit this form, it will be sent to the appropriate person.

In connection with your application and for other employment purposes, the Diocese of Dallas may seek background information about you from a consumer reporting agency. This information will be in the form of consumer reports and/or investigative consumer reports.

These reports may be obtained at any time after the Diocese of Dallas receives authorization from you, including any time during the period of your employment if the Diocese of Dallas hires you.

Consumer reports include any written, oral or other communication of information by a consumer reporting agency bearing on your credit standing, character, general reputation and other characteristics that is expected to be used for employment purposes. Consumer reports may include criminal records, and driving records, among other resources.

Accutrak, or another consumer reporting agency, will obtain the reports for the Diocese of Dallas.

You have the right to request information from the Diocese of Dallas about the nature and scope of any investigative consumer report on you that is requested by the Diocese of Dallas. The request must be made in writing and within a reasonable period of time after you have received this disclosure.

* required fields.

Personal Info

Title

First Name *

Last Name *

Suffix

E-mail *

Place of Birth (City, State)

Date of Birth *

/ /

Gender

Emergency Contact

Emergency Number

Address Info

Your current primary address is required. Please enter any additional addresses where you have lived in the past five years. To add an additional address, click the plus sign.

Street Address

City

State

Zip

Phone Info

At least one phone number is required.

Home Phone

Work Phone

Cell Phone

Ministry Info

What type of ministry work do you prefer? One or more items can be selected or
deselected from the following list by holding
down the Ctrl key and clicking the left mouse key.

Location Info

Please enter locations/positions where you currently or are applying to volunteer/work. Click the plus sign to add additional locations/parishes.

Location *

Position *

Title

Are you a registered member of any location? Select the location below, and time the date since you have been registred:

Active since /

References

List three personal references you have known three years or more who are not former employers or members of your immediate family. Email is not required but highly recommended.

Reference 1

First Name *

Last Name *

Street Address *

City *

State *

ZIP *

Daytime Phone Number

E-mail (Highly Recommended)

Reference 2

First Name *

Last Name *

Street Address *

City *

State *

ZIP *

Daytime Phone Number

E-mail (Highly Recommended)

Reference 3

First Name *

Last Name *

Street Address *

City *

State *

ZIP *

Daytime Phone Number

E-mail (Highly Recommended)

Background Info

Because the Diocese of Dallas cares for our children, youth and adults and desires to
protect them, we ask you to please answer the following questions. We understand the
following questions are personal and we will take all reasonable precautions to protect
your privacy.

Are you presently abusing alcohol or using any illegal drugs?

Yes No

Have you ever been convicted of, pleaded guilty or no contest to, placed on probation for, given
probation, given community supervision, or given deferred adjudication for a crime or are you now
under charges for any criminal offense?

Yes No

Answering yes to these questions will not automatically exclude you for volunteering. The following
lines are for any explanations or details that you would like to include for yes answers above.

Volunteer/Applicant Release Statement

Read Carefully!

The information contained in this application is true and correct to the best of my
knowledge.

I understand that all criminal background checks will be treated as confidential, and any questions or information about the results may be obtained ONLY by my contacting the diocesan approved vendor.

I understand and authorize the access to any and all information and records relating to
my criminal history or criminal offenses committed or alleged, arrests, alleged criminal acts
and criminal offenses committed.

I understand and authorize any references, or any other person or organization, whether
or not identified in this application, to give any information (including opinions) regarding
my character and fitness for service.

I hereby release any reference contact, whether identified or not in this application, and
waive any and all claims, liability for damages of whatever kind or nature which may at any
time result to me, my heirs/family, on account of compliance with this authorization,
excepting only the communication of knowingly false information.

I am aware that background checks may be updated periodically.

If a disqualifying offense is found on a criminal background check, there is an appeal
process in the Safe Environment Program. I understand that this process allows me to
verify information and correct any errors.

I intend this to be a legally binding release, which I have read and understand. I
understand that I may consult with an attorney before signing this document. A facsimile
or photocopy of this authorization shall be as valid as the original.